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They yell, they cuss, they throw things. Or they engage in more subversive behaviors: ignoring questions, acting impatient, insulting colleagues or speaking to them in condescending tones.

“It can go from verbal abuse to sexual harassment and physical assault,” said Dianne Felblinger, an associate professor of nursing at the University of Cincinnati who studies medical intimidation.

The acts are bad enough when they affect staff morale, leading to greater turnover and less job satisfaction. But the Joint Commission, a national hospital accrediting agency, warned Wednesday that there’s mounting evidence that such disruptive behaviors are tied to medical errors that can cause patient harm — and that hospitals across the country should no longer tolerate it.

Starting in January, the agency will require hospitals to establish codes of conduct that define inappropriate behaviors and create plans for dealing with them. Suggested actions include better systems to detect and deter unprofessional behavior; more civil responses to patients and families who witness bad acts; and overall training in “basic business etiquette,” including phone skills and people skills for all employees.

The Joint Commission’s first-ever alert about the problem is the latest industry effort to address an issue that has challenged the medical community for years, said Dr. Gerald Hickson, director of the Center for Patient and Professional Advocacy at Vanderbilt University Medical Center in Nashville, Tenn.

“The data is clear that certain members of the team don’t play so well with other members of the medical team,” said Hickson. “We’ve dealt more effectively with drugs and alcohol than we have dealt with the kicking, spitting and cussing.”

Dr. Mark Chassin, president of the Joint Commission, said growing emphasis on preventing medical errors has made it clear that a culture of intimidation contributes to the mistakes.

"It's a problem that goes underreported, threatens patient safety and has become so ingrained in health care that it's rarely talked about," Chassin told reporters Wednesday.
Nearly everyone who has worked in hospitals can recount a tale of bad behavior. Hickson recalled a doctor who hurled a table across a room, sending shards flying back at co-workers. Felblinger remembered when a doctor threw a used needle at a nurse, piercing her skin.

Don't ignore bad behavior
Ignoring bad behavior has potentially serious consequences for patients, said Felblinger, author of an analysis of studies on medical bullying published this spring in the journal of Obstetric, Gynecologic & Neonatal Nursing.

About 70 percent of nurses studied believe there’s a link between disruptive behavior and adverse outcomes, and nearly 25 percent said there was a direct tie between the bad acts and patient mortality, she said.

A 2004 study of workplace intimidation by the Institute for Safe Medication Practices (ISMP) in Horsham, Pa., found that nearly 40 percent of clinicians have kept quiet or ignored concerns about improper medication rather than talk to an intimidating colleague.

Linda Petitt, 54, a clinical nurse specialist in Cincinnati, Ohio, said she went into private practice several years ago because she could no longer tolerate the atmosphere that allowed a doctor to scream and yell in an operating room — with no repercussions.

“He told me: I refuse to talk to you, so now what are you going to do about it?” said Petitt, who was the charge nurse at the time.

Only a small percent are bad actors
Estimates based on malpractice claims suggest that between 4 percent and 6 percent of doctors and other health workers actually engage in intimidation, Hickson said. That’s probably about the same percentage of bad actors in any profession, he added.

But that small proportion has a big impact, said Felblinger.

“I think it is endemic,” she said. “We’ve been so used to having these behaviors occur for so long.”

In the ISMP study of about 2,000 clinicians, more than 90 percent said they’d experienced condescending language or voice intonation; nearly 60 percent had experienced strong verbal abuse and nearly half had encountered negative or threatening body language.

“Some people are intimidated because they think the doctor has the higher authority,” said Renee Setteducato, 55, a nurse at Lutheran Medical Center in Brooklyn, N.Y.

It’s important to note that bad behavior is not limited to doctors, said Dr. Joseph Heyman, chair of the board of directors for the American Medical Association. The Joint Commission warning also covers nurses, pharmacists and other clinicians, he noted.

It's not just doctors
Setteducato observed her share of tantrums and slammed phones in 37 years of nursing. But it’s not just doctors bullying nurses, she said. Nurses do their share of intimidation, too.

“The experienced nurses are not patient with the new doctors,” she observed.

The AMA has had a policy calling for zero tolerance for disruptive behavior for all workers for years. Heyman said he believes the climate is much better now than when he was a resident in the 1970s.

“I don’t see it as a huge problem,” he said, adding: “Having standards encourages hospitals to look for this kind of behavior and head it off at the pass.”

The Joint Commission standards and suggestions will offer hospitals a clear model for establishing guidelines and consequences that will help decrease disruptive behavior, Hickson said. He said he was optimistic that hospitals would actually put the plans into practice, mostly to improve workplace morale, but also to boost patient safety — and head off legal trouble.

“When they feel that a physician doesn’t care for them, he won’t return their calls, won’t answer their questions, those are the kind of events and circumstances that will be the last straw,” he said.

The new guidelines are a fine effort to address a long-standing problem, experts said, but it could take years for a major culture shift. In the meantime, there’s no substitute for professional confidence, said Setteducato, the veteran nurse.

Faced with arrogant doctors or those who scream and throw patient charts on the floor, Setteducato adopts a practiced, calm response. "You have to nip that in the bud," she said.

“I say, ‘You know what, doc? That doesn’t work here. And we’re going to have to do this together as a team. Because that’s what it’s all about.'”